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Chika- SF2 > Clinical Application of Stroke- Oyawusi > Flashcards

Clinical Application of Stroke- Oyawusi Flashcards

1
Q

What is the difference between ischemic and hemorrhagic stroke?

A
  • ischemic stroke results from occlusion of cerebral vessels
  • hemorrhagic stroke results from rupture of cerebral vessels
  • ischemic is the most common (80%)
  • stroke is the fifth leading cause of death in US
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2
Q

What are the modifiable risk factors?

A

things people can amend by taking medications of changing lifestyle that increase changes of stroke or recurrence

  • hypertension
  • diabetes
  • heart disease
  • dyslipidemia
  • atrial fibrillation
  • carotid artery disease
  • obstructive sleep apnea, hematological disorders, drug abuse (especially cocaine), cigarette smoking, excessive alcohol intake, obesity, oral contraceptive use (especially those with estrogen)
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3
Q

What is one big fact to know regarding causes for stroke?

A

33-40% of strokes involves large vessel occlusions!!

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4
Q

87% of strokes are of what type and what are they characteristic of? What about 13% of strokes?

A

87% is ischemic

  • cardioembolic
  • large vessels
  • small vessels

13% is hemorrhagic

  • intracerebral hemorrhage (bleeding into the parenchyma)
  • subarachnoid hemorrhage
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5
Q

What are a non modifiable risk factor for stroke?

A

-AGE: stroke rises with age (over the age of 75- 12.7 men and 10.7 women will have stroke)
-GENDER
RACE/ETHNICITY
FAMILY HISTORY OF STROKE
PRIOR STROKE, TIA, HEART ATTACK

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6
Q

What are the risk factors of stroke for women?

A
  • hypertension
  • migraine with aura
  • atrial fibrillation
  • diabetes
  • depression
  • emotional stress
  • post menopausal state and hormonal status
  • pregnancy, childbirth, and pre-eclampsia
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7
Q

How do you recognize stroke/TIA when it comes into the ER? What are the symptoms?

A

SUDDEN ONSET of neurological deficits

  • focal weakness
  • focal sensory disturbances
  • loss of vision in one eye or visual field
  • speech disturbances
  • vertigo: dizziness with rotational component
  • ataxia: gait imbalance
  • diplopia: double vision
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8
Q

What is the acronym used to deal with a stroke?

A

TIME IS OF THE ESSENCE!!!! (FAST)

F ace drooping on one side
A rm weakness on one side
S peech jumbled, slurred, or lost
T ime to call 911

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9
Q

How do you rule out a hemorrhagic stroke? What test do you perform?

A

head CT (non-contrast)

-if there is no hypodensity on the head CT patient can be given tPA which is one of things to treat pt with an ischemic stroke acutely

bright white on a head CT is fresh blood

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10
Q

What should consist of the evaluation for stroke/TIA?

A
  • history for time of onset of symptoms, predisposing factors
  • vital signs and state of consciousness (are they awake or alert enough to protect their airway)
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11
Q

How do you a stroke is localized to the right brain?

A

Right brain: right gaze (left frontal eye field is intact pushing the eyes to the right), left hemineglect (if the right parietal region is involved), left hemisensory (visual/ tactile, or auditory stimuli), left hemiparesis, left hemianopsia

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12
Q

How do you a stroke is localized to the left brain?

A

Left brain: left gaze, right hemiparesis, right hemisensory, right hemianopsia, aphasia (Broca’s (decreased speech production, problem with fluency, exchange words like dork for fork), expressive, receptive)

-if temporal lobe was affected it would be Wernicke’s problem understanding speech, word salad nonsensical speech

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13
Q

How do you a stroke is localized to the brainstem?

A

Brainstem: CROSSED SIGNS; cranial nerves: diplopia, facial weakness, vertigo, tinnitus swallowing problems, hiccups, vomiting; Quadriparesis or hemiparesis

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14
Q

How do you a stroke is localized to the cerebellum?

A

cerebellum: ataxia, imbalance, incoordination

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15
Q

What are symptoms for stroke involving middle cerebral artery?

A

superficial aphasia, hemineglect, contralateral hemiparesis, sensory deficit of face, arm

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16
Q

What are symptoms for stroke involving anterior cerebral artery?

A

involving the leg fibers in the homunculus

-contralateral leg weakness and sensory deficit

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17
Q

What are symptoms for stroke deep within the hemisphere?

A

contralateral hemiplegia, hemisensory deficit, homonymous hemianopsia

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18
Q

What are symptoms for stroke involving posterior cerebral artery?

A

contralateral homonymous hemianopsia, visual agnosia, prosopagnosia (in temporal lobe specifically), simultanagnosia (lesion in occipital lobe associated with the temporal lobe; cannot identify any object)

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19
Q

What are symptoms for stroke involving vertebrobasilar artery especially PICA?

A

-lateral medullary syndrome (Wallenburg syndrome): VASST
-vestibular: ataxia, dizziness
-ambiguus: hoarseness, dysphagia
-sympathetic: Horner’s syndrome
Spinothalamic tract: deficits with picking up pain and temperature

-crossed clinical syndromes, ataxia, vertigo, diplopia

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20
Q

What does hypodensity mean on a head CT for a patient coming in with stroke symptoms?

A
  • that identifies an area of infarction
  • this means the pt cannot be given tissue plasminogen activator (tPA)
  • the tissue (very friable and delicate) would be at risk for hemorrhage if we give them antiplatelet therapy
  • ideally you would want a clean head CT to give tPA

bleeding would be hyperdensity

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21
Q

Why is time of the essence when it comes to strokes?

A

for every minute after stroke the brain loses:

  • 1.9 million neurons
  • 14 billion synapses
  • 7.5 miles myelinated fibers
22
Q

What is tPA and what is its function?

A
  • Tissue plasminogen activator
  • breaks up clots
  • pt should receive this medication within 3 hours of the onset of symptoms (if not risks of giving medication outweigh benefits)
  • physician should try to achieve a door to needle time within 60 minutes in at least 50% of ischemic stroke patients treated with IV tPA
  • tPA does not reverse
23
Q

Who is intravenous rt-PA is recommended for?

A

recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke

24
Q

What is the thrombolytic therapy checklist?

A

≥18 years of age with ischemic stroke < 3 hours

Deficit found to be potentially disabling; severity quantified with NIH stroke scale (0 - 42 scale)

figure out the coagulation status; find if they are on anticoagulants (Warfarin or Plavix)

test INR (which should be ≤ 1.7) and normal PTT

measure platelet level which should be > 100,000

blood pressure SBP < 185 mm Hg, DBP < 110 mm Hg

glucose > 50 mg/dL

no evidence of intracranial hemorrhage on pretreatment CT

clinical presentation is suggestive of a subarachnoid hemorrhage

NO active internal bleeding of any kind in the body (vaginal, etc.)

no intracranial surgery or trauma or previous stroke

On repeated measurements, SBP greater than 185 mm Hg or DBP greater than 110 mm Hg at the time treatment is to begin.

NO history of intracranial hemorrhage or Known arteriovenous malformation, or aneurysm

25
Q

If a patient went to bed at 10 pm the night before perfectly but woke up at 7 am experiencing stroke like symptoms, would you give them tPA?

A

no because the onset of symptoms is ambiguous

26
Q

Once the patient comes in to the ER, what is the time frame that they should be seen and by whom? What should be done?

A
  • within 10 minutes preferably by a neurologist
  • plain head CT (to rule out bleed, hypodensity, or a large infarct); contrast to look at BVs

not MRI because it takes about 45 minutes

neurologist would have read T and ideally within an hour the pt would receive tPA if CT is clean

27
Q

What are the two scales used to note what the patient’s deficits are?

A

modifying ranking score (prestroke mRS should be between 0 and 1)

0= completely independent and can take care of themselves 
5= nursing; will be less likely to be sent for a thrombectomy

NIH stroke scale (should be at least a 6)

28
Q

63 year old female with h/o ischemic cardiomyopathy (ICM), congestive heart failure (CHF) with left ventricular assist device (LVAD) with INR of 2.2 who presented with RMCA syndrome.

NIHSS: 21
Last known well: 4: 00 pm
Arrival Date/Time: 6:05 pm

Is she a candidate for tPA?

A

NOOOO her INR is too high
but you can do a thrombectomy (NIHSS is >6 meaning she has a lot of deficits and a large artery is involved)

-do the CT angiogram of head and neck

Time to IR Suite: 6:35 pm
Groin Puncture Time: 7:05 pm
First Pass with Catheter: 7:11 pm
Recanalization Time: 7:33 pm
TICI

NIHSS at 24 hours: 9

Patient discharge to acute rehab in 4 days

29
Q

Once someone has a stroke they are at risk for having another one. What are some measures the patient should be advised to take?

A
  • place pt on appropriate hypertensives
  • appropriate antilipidemic agent (statin)
  • glucose is controlled well
  • lifestyle changes( stop smoking, drinking)
30
Q

What are the causes of ischemic strokes?

A

large vessel disease:

  • cervical, within the neck the internal carotid arteries could be blocked
  • intracranial arteries can be blocked

small vessel disease:

  • can occur if pt has hypertension
  • cardioembolic: arrhythmia like atrial fibrillation; increased risk of formation of a thrombus that could break up into chunks and form and emboli

-other less causes: arteritis, dissection (especially carotid), sickle cell fibromuscular, dysplasia, hypercoagulable state

31
Q

What are watershed strokes? KNOW THIS

A

strokes that occur in between vascular territories and tend to be cortical

due to dectreased perfursion

32
Q

What are lacunae infarctions?

A
  • cause small vessel disease
  • due to hardening of arteries
  • due to dyslipidemia, calcification of arteries etc.
33
Q

Define TIA.

A

transient ischemic attack

  • occurs because there is decreased perfusion to an area but its not complete like an infarct or occlusion
  • a majority of TIA do not have neuroimaging signs

-most TIA are stroke like symptoms that occur within less than an hour
the time cut off for symptoms is one hour

34
Q

Why do we use tPA for patient who do not have a clot in the major artery?

A

it is a clot buster; it is a major blood thinner

need to have < 185/110

35
Q

What is the EXPRESS study?

A

Oxford, England - introduction of daily TIA/minor stroke clinic (what we should for pts with a TIA)

  • Median delay in assessment fell from 3 days to 1 day
  • Median delay to first prescribed treatment fell from 20 days to 1 day
  • The 90 day stroke risk fell from 10.3% to 2.1%.
  • they saw that having a delay in the assessment fell from 3 to 1 days
  • improved how the clinicians assess the patients when they started interventions
36
Q

When is MRI most appropriate to use according to AHA ASA?

A
  • when you’re doing neuroimaging to evaluate stroke especially the DWI for acute lesion
  • one of the MRI sequences
  • used to evaluate for acute and older lesions/strokes
  • DO NOT give to pts with metal in their body (defibrillator/pacemakers)

but do a CT when pt first comes in remember time is of the essence

37
Q

Why should non-invasive imaging of cervical vessel be performed routinely?

A

along with the CT scan you get to the CTA to look at vessels in the head and neck

-if the pt may be a candidate for a thrombectomy
-a subacute intervention
carotid endarterectomy or carotid stents

38
Q

What percentage of occlusion needs to be present for carotid endarterectomy?

A

70-90% occlusion of the affected carotid artery

39
Q

Why is an ECG performed?

A
  • to make sure there is no clot in any of the ventricles
  • to look for atrial fibrillation which is one of the risk factors for stroke

In the ECG look for:

  • PFO (TTE bubble study, TEE, or TCD)
  • Aortic arch atherosclerosis (TEE)
  • Valvular disease (TEE)
40
Q

KNOW THIS: Only if cryptogenic: hypercoagulable evaluation. Why?

A

if the patient is young and without the usual risk factors (Cryptogenic); maybe they have a genetic predisposition so you do a hypercoagulable test

41
Q

Secondary prevention of stroke is important/key because once someone has a stroke, they are at risk of having it again. What are the medical interventions?

A

antiplatelet therapy usually aspirin and other things:

  • aspirin (doses 81-325)
  • Clopidogrel
  • Aspirin + clopidogrel
  • Aspirin + dipyridamole
42
Q

What is the overall goal of antihypertensive therapy, Hb A1c, cholesterol (LDL, give statin) ?

A

BP <130/80
HbA1c ≤ 7
LDL goal <100 for those without DM, but with DM as a comorbidity <70

43
Q

When would you do a carotid stenosis?

A
  • CEA urgently (carotid endarterectomy)
  • not just if they have stroke on affected side but they have symptoms of TIA that correlate with narrowing of the artery
44
Q

What are the areas of the brain that you are at highest risk to see intracranial hemorrhage due to hypertension?

A
  • Basal Ganglia (KNOW THAT THIS IS NUMBER ONE especially putamen)
  • Thalamus
  • Centrum Semi-ovale
  • Pons
  • Cerebellum – Neurosurgical Emergency
45
Q

What are the classical symptoms for intracerebral hemorrhage?

A
  • Sudden Severe headache
  • Altered Sensorium
  • Focal Neurological Deficit depending on location of hemorrhage
46
Q

The location of the subarachnoid hemorrhage are usually where?

A

85% Subarachnoid space (Circle of Willis)

15% Sylvian fissure – MCA trifurcation

47
Q

About 7% of strokes secondary to aneurysmal rupture. What vessels are at risk of aneurysms?

A

due to small vessels that have branch

48
Q

What are the symptoms of subarachnoid hemorrhage?

A

no focal neurological deficits (unlike intracerebral hemorrhage)

Sudden Severe Headache!!!!
Altered Sensorium
No focal neurological deficit
Signs of meningeal irritation – neck stiffness, Brudzinski’s sign, Kernig’s sign
Oculomotor Nerve at onset of headache – Ipsilateral Posterior Communicating artery aneurysm rupture

49
Q

KNOW THAT the first signs of rupture or aneurysm of Ipsilateral Posterior Communicating artery

A

ptosis, then wide eye (dilated pupil) because

the oculomotor controls the ciliary muscle which dilate

50
Q

What are neurological complications of strokes/TIA?

A
  • Progression of thrombosis
  • Recurrent embolism
  • Brain edema
  • Hydrocephalus (SAH)
  • Increased Intracranial Pressure
  • Hemorrhagic Transformation (the tissue very friable and delicate would be at risk for hemorrhage if we give them antiplatelet therapy)
  • Seizures are positive symptoms (strokes are negative symptoms)
51
Q

What are the medical complications that can occur with stroke/TIA?

A
  • Pneumonia
  • Airway Obstruction
  • Hypertension
  • Bladder Infections
  • Depression
  • Electrolyte Disturbances
  • Myocardial Infarction
  • Congestive Heart Failure
  • Cardiac Arrhythmias
  • Deep Vein Thrombosis
  • Pulmonary Embolus
  • GI Bleeding (any bleeding diathesis)

Chika- SF2 (63 decks)

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